Name:
High Tibial Osteotomy
Description:
High Tibial Osteotomy
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/deb5c3b4-63b9-42dd-8092-e48bb96ef089/videoscrubberimages/Scrubber_1.jpg
Duration:
T00H09M28S
Embed URL:
https://stream.cadmore.media/player/deb5c3b4-63b9-42dd-8092-e48bb96ef089
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/deb5c3b4-63b9-42dd-8092-e48bb96ef089/3_ High Tibial Osteotomy- v1 - bdf.mov?sv=2019-02-02&sr=c&sig=1LDq2rZOYrzlE5bimd6h85zumtbIBL0FDjMQ8zGhwec%3D&st=2024-11-21T18%3A03%3A32Z&se=2024-11-21T20%3A08%3A32Z&sp=r
Upload Date:
2024-05-31T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
ROBERT ROZBRUCH: Hi. This is Dr. Rob Rozbruch from the Hospital for Special Surgery. I'm the Chief of The Limb Lengthening and Complex Reconstruction Service. This live surgery video on correction of bowlegged deformity is going to help illustrate our approach to genu varum correction. These are the long X-rays of a 25-year-old male with bilateral genu varum or bow legs.
ROBERT ROZBRUCH: He complains of medial knee pain and has concerns about future arthritis. The surgical plan is to do bow leg deformity correction with an opening wedge, proximal tibial osteotomy technique, locked plate fixation. This is a bilateral, which is done in a staged fashion. The left side was done. The side that's being illustrated today is the right side.
ROBERT ROZBRUCH: You'll notice on the right side that the M.A.D; the mechanical axis deviation is 20 millimeters medial to the midline. Ideally that should run to the center of the knee. This long standing x-ray looks at the joint orientation angles and the M.P.T.A. of 80 degrees confirms that the deformity is coming from the tibia. You'll notice on this x-ray the left side has already been done.
ROBERT ROZBRUCH: This x-ray shows osteotomy planning and what you can see here is a 6 degree deformity with the cora or apex of deformity in the proximal tibia. This allows us to plan the location of the osteotomy and also allows us to plan the size of the opening wedge using a trigonometric formula. This x-ray shows an animation of the correction with the opening wedge in place and gives us a sense and confirmation of the size of the wedge, which in this particular case is going to be 6 to 7 millimeters.
ROBERT ROZBRUCH: So let's get on with the surgery. This is the exposure from the medial side, it's a 7 centimeter skin incision. You can see here I am dissecting anteriorly under the patellar tendon. I need to create a space under the patellar tendon so that we can properly protect it. We're going to put a right angle retractor protecting the patellar tendon, as you'll see from the osteotomy.
ROBERT ROZBRUCH: The top part of the incision needs to be able to fit the plate. The plates' used as a template for planning the osteotomy location. So this is where I think the plate is going to sit, I provisionally put in a proximal wire. I check the orientation of that on the X-ray to make sure that it's in an optimal location and that's where I know I can start my osteotomy between those two screw holes and I'm marking the bone in that particular location.
ROBERT ROZBRUCH: This is the wire that I'm inserting to create my osteotomy line. The starting point was based on the location of the plate. These x-rays show the wire planning the osteotomy and this is an optimal orientation. It's an oblique osteotomy headed in this particular direction. Now, at this point, you can see I've got retraction posteriorly behind the tibia and anteriorly under the patella tendon, and we've cut the wire short so we're ready to start performing the osteotomy.
ROBERT ROZBRUCH: I use a micro sagittal saw for this. I'm outlining the exact orientation of the osteotomy, which is going to be anterior to posterior on the back part, but then anteriorly as you're going to see, it's going to turn in an oblique fashion and go under the patellar tendon or posterior to the patellar tendon. This is really important because this makes it so that I do not injure the patellar tendon insertion on the tibial tubercle.
ROBERT ROZBRUCH: I can remove the orientation wire at this point, complete the osteotomy and then use osteotomes to gradually mobilize the osteotomy. Key point here is not to perform an osteotomy through the lateral cortex. You're hinging on the lateral cortex with this technique, so we use these graduated osteotomes to start mobilizing the osteotomy on both parts, the both limbs of the osteotomy.
ROBERT ROZBRUCH: I'm careful not to put it in too far and I'm sensitive to the depth measurement so as not to break the lateral cortex. This is a thicker osteotome, which starts to spread the osteotomy more effectively and this will allow me to insert Lamina spreaders, which I'm going to do anteriorly and posteriorly, and then gradually I can distract the Lamina spreaders. In this particular case, our goal is about 6 to 7 millimeters based on the preoperative planning, and we'll get some additional confirmation.
ROBERT ROZBRUCH: I use an osteotome that I know it's particular with and it will allow me to dial this open to the optimal point. We'll also use a little wedge that are set that allows us to determine the exact size of the opening wedge. At this point, we do an intraoperative alignment test and we run a rod from the center of the hip to the center of the ankle and then x-ray the knee and look at the mechanical axis line. Here
ROBERT ROZBRUCH: you can see the images. This is the center of the knee, center ankle and center hip, and based on the location of that line, we can additionally open it or close it a little bit to achieve the optimal location. Again, you can see the spreading of the osteotomy medially. I know the exact size of the opening wedge and I'm getting ready to insert my tri cortical allograft strut. By removing one of the Lamina spreaders,
ROBERT ROZBRUCH: I have room to insert the tri cortical piece of bone. Once it's in place, it's actually quite stable because it's hinging on the lateral cortex. The next step is irrigation, and while I have really good exposure, I'm going to insert freeze dried allograft chips into the space. This has high healing potential and all you really need here is a good scaffold for the osteoblasts to grow across.
ROBERT ROZBRUCH: We've had very predictable bony union using this technique. The chips are inserted, they're impacted lightly, and you get a nice fill. The next step is going to be the insertion of the plate. Everything is quite stable right now. The plate is provisionally held with two wires, which I can x-ray at that point to make sure it's properly oriented on the AP x-ray and the lateral x-ray,
ROBERT ROZBRUCH: and if it is, then we'll proceed and insert the rest of the screws. These are locked screws. Using this particular plate, we drill with a 4.3 millimeter drill and insert 5 millimeter locked screws. The proximal cluster of screws are, do not go through the far cortex and the distal screws are bi cortical. If the plate happens to be sitting up off the bone, you can either bend the plate a little bit or you can use a non locking cortical screw to pull the plate to the bone.
ROBERT ROZBRUCH: The distal hole is done in a percutaneous fashion to minimize the length of the incision. Final x-rays are taken, which confirm the position of the plate. The final bone graft material I use is a de mineralized bone matrix putty, which I use as spackle to hold the graft in place.
ROBERT ROZBRUCH: I insert a drain routinely because this is all done with the use of a tourniquet, and I don't drop the tourniquet until after the closure is complete. The deep layer is closed with zero vicryl suture to close, to cover the plate and the subcutaneous tissues are closed with Monocryl and we typically use a Monocryl sub cuticular closure for the main incision.
ROBERT ROZBRUCH: There's no cast or brace necessary after this procedure, knee range of motion is not limited in any way, and they are typically kept 50% partial weight bearing for a period of four to six weeks, depending on the patient and depending on the healing. Almost all patients at six weeks are ambulating, full weight bearing without crutches.
ROBERT ROZBRUCH: These are the x-rays AP of the knee at six weeks showing really good consolidation of the osteotomy. These are standing x-rays after both sides were done, they were separated about six weeks showing correction of the bow leg alignment. These are preoperative clinical views showing the genu varum or bow leg deformity from the front and from the back. This is a post op when both sides were done showing really good correction of the bow leg alignment.
ROBERT ROZBRUCH: I hope that you have found this video to be instructive. Again, this is Dr. Rob Rozbruch from Hospital for Special Surgery.
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